October 2016

Date: 01 October 2016

  • Details:

    The patient fell over and was in a lot of pain. The crew assessed the patient. The patient was unhappy and shocked to be left at home, with advice to take painkillers and to keep mobile. The patient had been in a lot of pain for around 5 weeks and eventually had an x-ray, where it was found that they had a compressed fracture of the spine T12. The patient believes they should have been immobilised and taken to hospital. 

  • Findings:

    The investigating manager reviewed the Patient Care Record and met with the crew and discussed the incident at length. The patient also gave consent for the investigating manager to review her hospital records.  The crew spent an hour a half with the patient completing a comprehensive assessment which was recorded on the PCR. The patient had no midline spinal tenderness and no neurological makers for a spinal injury, although compression fractures of the spine often cause no symptoms. The patient had a history of chronic back pain and the radiographers report states that there is no acute bony injury to the vertebrae. There was midline spinal tenderness and no neurological makers for a spinal injury.  From the history of events and the clinical findings of the crew it was their view the compression fracture suffered was from the chronic condition and not caused by the fall, however this may have been aggravated by it.

  • Lesson learnt / action taken:

    The crew performed a meticulous examination and gave the patient advice and treatment from what they found at the time, they also gave advice to contact your GP is the symptoms became worse. The crew acted in the best interests of the patient and in accordance with clinical protocols. Apologies were provided to the patient for the distress caused.  Although the crew treated the patient correctly at the time they have both reflected on this incident and have both completed extensive research into compression fractures for future reference.

  • Date:
    30 September 2016